Can you give additional doses of a PRN to increase an already given dose to a range?

[suanna]

Hypothetical situation: Your patient is ordered 4 to 8 mg of Morphine IVP for pain>4 on 1-10 scale, Q2 hrs PRN. The first dose you give is 4mg, but 30min later he states his pain is unrelieved. I know what I "would" do, but legaly (I'm in Ohio) once you have chosen the 4mg dose, don't you have to wait until the next dose window-in this case 2hrs- before you can give an 8mg dose, or can you give an additional 4mg within the 2hr window to add up to the maximum ordered dose?

If you can give an additional dose- where do you begin the 2hr window- from when you started giving the 8mgs with the first 4mg, or from the 2nd 4mg where you finished giving the 8mg dose?

If anyone has a definitive legal answer to this question please let me know, and where you got this answer. We are in quite a discussion at work.

[I<3H2O, BSN, RN]

Our P&P where I work is very vague and does not cover this topic well. It is generally understood however that if you have an order for Morphine 4-8mg q4hr PRN pain then we give the 4mg first. Reassess the pain in 15 minutes. If pain is not controlled we can give more (most just give the other 4 to maximize the dose however you could technically give 1mg at a time until you reach the 8mg). Once pain control is achieved, you start the 4 hours from that last dose of med. If you end up giving a TOTAL of 8mg then that is what you start with the next time the pt. needs pain med.

The PROBLEM in my unit is this: You have an order for 4-8mg of Morphine q4hr PRN pain AND you have an order for Lortab 7.5/500 1-2 tabs q4hr PRN pain. Some nurses feel like this is written so that the pt. has something for pain q2hr. Other nurses feel this means you get something for pain q4hr whether that be Morphine or Lortab. Different doctors take it to mean different things. My head is spinning trying to figure out what to do half the time. One nurse we work with will actually call ppl to the carpet for giving pain med q2hr and will call them stupid, unsafe, etc. in a very loud and inappropriate manner!

[LTCangel, ADN, BSN, LPN]

When I worked the floor(Orthopedics) we often had these type of orders for IV meds and pain pills. I always tried to alternate the IV with the po if the patient was having pain control issues(and they usually were). It meant me going in their room every 2 hours but it also meant a much happier patient and family. I did not want to see my patients in pain especially with fresh fractures or post-op or fresh joint replacements. Pain control was always the most important intervention involved. Meds along with proper positioning and ice were invaluable. Also if the patient knew I wasn't going to let them lay there and "suffer" we got along very nicely. A patient in pain who is at the mercy of a "pain Nazti" always makes me upset. There is no need for this especially if you have the meds ordered to give than just give it. Yes if I had an order written the way the OP stated then I would go ahead and give the rest of the dose within the 2 hour time frame and then start timing again from there. You will also build a good trust relationship with your patient. Of course, when in doubt call the doc and make them get rid of these range orderes that can be hard to interpret, and maybe order a PCA if the pt is requiring that much IV push meds. Our hospital was trying to get the docs to stop writing range orders like that for the very reason that they are open to interpretation in different ways. And of course, always monitor those O2 sats. Some pts can take a lot, others, it will build up and the pt can crump! Sat monitors are available on the med-surg floor ot at least they were on mine!:)

[meandragonbrett]

Nothing would be given at my hospital until the order was clarified or rewritten. Range orders are NOT allowed with dosage or with time.

What would be an acceptable order at my facility would be "Dilaudid 0.5mg IV q10min PRN 1.5mg/hr max dose"

[suanna]

I'm all for pain control as well, but I'm mostly looking for any information about what the Joint Commission or BON, or pharm regulations say on the issue. I took some CEU hrs on pain management a few years back and I'd swear they said it was common practice to give an additional dose up to the max ordered for the time window, but it wasn't strictly legal. My original quandry still remains unanswered- do you give your next dose 2hrs from when you gave the 2nd dose(completeing the 8mg dose) or from the 1st 4mg when you initiated the 8mg dose. The patient may end up having to wait longer for pain relief if you have to wait for the interval to pass from the 2nd half. If you had given the entire 8mg at the first intervention, a 2nd dose of 8mg could be given 2 hrs later, but if you gave 4mg, then 1hr later gave 4mg and timed your next intervention from that dose, it will be 3hrs from the start of your interventins before you can give a 2nd 8mg dose, not the ordered 2hrs. If you did give it 2hrs from the initial dose, the 4mg you gave "to complete the dose" plus the next 8mg dose would result in an actual 12mg dose in a 1hr window. My head spins like it did when I took "statistics" in my undergrad classes. It all depends on how you look at it- but this isn't semantics- it's narcotics, that in the real world can cost your patient a lot more than a "C" in a math class.

[MunoRN, RN]

I'm not in your state but I'm not aware of any state BON or pharmacy boards that get that specific on range orders. The Joint Commission does have guidelines (although they aren't laws since they are just an accrediting body) which state that each facility must have a policy that addresses range orders so that they are clear and consistently understood. They also suggest that these policies be based on evidence/best practice. Many hospitals have done away with range orders all together to ensure they pass the requirement for consistent understanding. There are best practice recommendations from the American Society of Pain Management Nursing and the American Pain Society which argue for flexible range order policies.

It really just comes down to your facility policy. Of those that still use range orders, most seem to require that you not give more than the high end of the range in any 4 hour period (or whatever timeframe is ordered). Although some allow you to give an additional dose (not exceeding the range) within one hour of original dose and then subsequent doses are timed off the initial dose.

[Tait, MSN, RN]

OP states it's a hypothetical situation.

Well then they need to hypothetically tell us where it is happening as this will affect the responses.

[Tait, MSN, RN]

I am starting to think if the patient needs 8mg of morphine they might be better off with a PCA.

There are a lot of institutional variables on this, as well as specifics to MD orders. Perhaps it is time for a Google on Joint Commission. Going to go snoop around.

[MunoRN, RN]

I am starting to think if the patient needs 8mg of morphine they might be better off with a PCA.

There are a lot of institutional variables on this, as well as specifics to MD orders. Perhaps it is time for a Google on Joint Commission. Going to go snoop around.

The Joint Commission standard on range orders is MM.3.20

[Tait, MSN, RN]

So here is JCAHO Range order recommendations: "Range orders Range orders may be written when the patient’s condition is unstable, or changing,

and should include assessment parameters, whenever appropriate. Adjustments within

the dose range are based on:

• Patient assessment

• Prior dose administered

• Time interval between doses, and

• Effectiveness of prior doses

• Policy requires that the RN start with the lowest possible dose and increase if

necessary by patient response"

http://www.factsandcomparisons.com/assets/hospitalpharm/jan2006_jcaho.pdf

So if one starts with the lowest possible dose, they aren't very clear here on how to proceed with the next dose.

Now I know we can no longer have two "variables" in the order. For example we can't have Morphine IV 2-4mg Q2-4 hours PRN pain.

To me it really looks like one needs to follow their specific hospital/area protocol. If you have the flexibility to administer meds until "comfortable" then I would personally time from the most effective dose and then continue with that dose for the next administration if the patient was A&O and comfortable. So if I gave 4mg at noon and 4 additional mgs at 1230 I would time the dose from 1230.

Unfortunately at our hospital they have taken the right away from us to start with the recommended JCAHO lowest dose. Perhaps there is an increase in patient oversedation related to this since the new system was implemented, due to nurses pulling larger doses in anticipation, since they know they can't go back in and scan an additional dose? Might have to ask a few questions at work when I get back!

[MunoRN, RN]

When the JC recommendations came out and some hospitals were starting to just do away with range orders, the increased potential for over-medication and oversedation was one concern, but the potential for under-treatment of pain was as well. Our risk management dept. was concerned that if there was no flexibility and ability to adjust parameters to pt specific pain scales and responses to pain, then MD might be more likely to write for a high enough dose to cover the majority of pain which may result in unnecessarily high doses of opiates and then result in more over-sedation- which is a popular reason to sue.

From a practice standpoint, we were also concerned that with less flexibility in treating pain that there may be lapses in pain control. Poorly controlled pain is associated poorer outcomes.

[honeykrown, MSN, NP]

Well then they need to hypothetically tell us where it is happening as this will affect the responses.

It was an hypothetical situation so we would be able to understand the question better and answer better

[wooh, BSN, RN]

I'm all for pain control as well, but I'm mostly looking for any information about what the Joint Commission or BON, or pharm regulations say on the issue.

Joint Commission? They don't really have a rule except that the hospital have a policy and that policy be followed.

Pharm regulations? That's basically just going to make sure we aren't diverting, so keep up with what you do give so it doesn't look like you took it home.

Boards of Nursing? Most aren't going to have a hard and fast rule either.

Point being, it's up to your hospital policy. But this situation is why I tend to give the higher dose in the range if the patient's history suggests they can tolerate it. I also like PCAs and transitioning to PO asap so I don't have sudden "loss" of pain control.